RESEARCH • RECHERCHE

Delays in the operating room: signs of an

imperfect system

Janice Wong, BS, MS Background: Delays in the operating room have a negative effect on its efficiency
Kathleen Joy Khu, MD and the working environment. In this prospective study, we analyzed data on periop-
erative system delays.
Zul Kaderali, MD
Methods: One neurosurgeon prospectively recorded all errors, including periopera-
Mark Bernstein, MD, MHSc tive delays, for consecutive patients undergoing elective procedures from May 2000 to
February 2009. We analyzed the prevalence, causes and impact of perioperative system
From the Division of Neurosurgery, delays that occurred in one neurosurgeon’s practice.
Toronto Western Hospital, University
Health Network, University of Toronto, Results: A total of 1531 elective surgical cases were performed during the study
Toronto, Ont. period. Delays were the most common type of error (33.6%), and more than half
(51.4%) of all cases had at least 1 delay. The most common cause of delay was equip-
Accepted for publication ment failure. The first cases of the day and cranial cases had more delays than subse-
Aug. 25, 2009 quent cases and spinal cases, respectively. A delay in starting the first case was associ-
ated with subsequent delays.
Correspondence to: Conclusion: Delays frequently occur in the operating room and have a major effect
Dr. M. Bernstein on patient flow and resource utilization. Thorough documentation of perioperative
Division of Neurosurgery delays provides a basis for the development of solutions for improving operating room
University of Toronto efficiency and illustrates the principles underlying the causes of operating room delays
Toronto Western Hospital across surgical disciplines.
399 Bathurst St., 4 West Wing
Toronto ON M5T 2S8
fax 416 603-5298 Contexte : Les retards dans les blocs opératoires exercent un effet négatif sur l’effi-
mark.bernstein@uhn.on.ca cacité de ces services et sur le milieu de travail en général. Dans cette étude prospec-
tive, nous avons analysé les données sur les retards affectant le système périopératoire.
Méthodes : Un neurochirurgien a noté de façon prospective toutes les erreurs, y
compris les retards périopératoires, pour les patients consécutifs devant subir des
interventions non urgentes entre mai 2000 et février 2009. Nous avons analysé la pré-
valence, les causes et l’impact des retards affectant le système périopératoire survenus
dans la pratique d’un neurochirurgien.
Résultats : En tout, 1531 chirurgies non urgentes ont été effectuées durant la péri-
ode de l’étude. Les retards étaient le type d’erreur le plus courant (33,6 %) et plus de
la moitié (51,4 %) de tous les cas ont subi au moins un retard. La cause la plus
fréquente des retards était une défaillance matérielle. Les premiers cas de la journée et
les cas de chirurgie crânienne présentaient plus de retard que les cas subséquents et
que les cas de chirurgie rachidienne, respectivement. Les retards affectant le début des
premiers cas se répercutaient sur les suivants.
Conclusion : Les retards sont fréquents au bloc opératoire et exercent un effet
majeur sur le roulement des chirurgies et sur l’utilisation des ressources. La consigna-
tion minutieuse des retards périopératoires constitue une base pour l’élaboration de
solutions en vue d’améliorer l’efficacité des blocs opératoires et illustre les principes
qui sous-tendent les causes des retards au bloc opératoire, dans toutes les disciplines
chirurgicales.

elays can be attributed to human errors and system deficiencies,1 and

D the surgical operating room is rife with both. Whereas preoperative

treatment delays have been associated with adverse consequences,2–7
very few studies have addressed the prevalence, causes or impact of periopera-
tive delays. Unlike preoperative delays, which include prolonged wait times or
postponements, perioperative delays occur on the day of the scheduled opera-
tion and include delays getting to the operating room and delays during the

© 2010 Canadian Medical Association Can J Surg, Vol. 53, No. 3, June 2010 189
RECHERCHE

operation. Perioperative delays are perceived to be ineffi- Error classification

cient and undesirable because they act as barriers to opti-
mal patient flow and are a source of frustration, but their The senior author developed a simple system to classify
causes and impact on patient care and resource utilization errors. The types of errors in this system were technical
are not well defined. However, solutions for inefficiencies (errors in the performance of a task by the surgeon or
in the operating room cannot be devised unless the delays assistant), contamination (instrument required resteriliza-
that occur on the day of surgery are better understood. tion), delays (long wait because of system inefficiency),
Currently, there is no consensus about how best to equipment (missing or malfunctioning equipment), com-
monitor delays or classify their causes. A study on operat- munication (failure in communication between members
ing room efficiency compared the prevalence and causes of of the operating team [e.g., no prophylactic antibiotics
perioperative delays before and after educational interven- given because the anesthetist did not hear the surgeon’s
tions.8 Sophisticated quantitative models have also been request]), management/judgment (insufficient preopera-
used to identify optimization strategies for operating room tive preparation [e.g., abnormal blood result was not cor-
efficiency.9–12 Other studies have attempted to quantify rected]), nursing (error on the part of the nurse), anesthe-
operating room delays, focusing on delays resulting from sia (error on the part of the anesthetist), and other.16
turnover between surgeries,13 admission into the postanes- For the purposes of this study, we included only data
thetic care unit14 and nonoperative time.15 Hospital records pertaining to delays. All equipment failures were consid-
may provide information about the prevalence of delays ered to be delays.
getting into the operating room, but they do not document We further classified the delays on the basis of cause
the myriad delays that occur during surgery, nor do they The types of delays were delays getting the patient into the
record the causes of the delays. Hence, despite the fact that operating room (later than 8:10 am for the first case of the
perioperative delays are experienced daily by both surgeons day and more than 1 hour after the preceding case for sub-
and patients, these delays and their causes have yet to be sequent cases), equipment failure (missing or malfunction-
regularly and thoroughly documented. ing equipment), quick section delay (quick section results
In this study, we report how perioperative delays can be received from the pathologist more than 30 min after sub-
identified, classified and analyzed using a prospective data- mission of the specimen), intraoperative radiography delay,
base accrued by the senior author over a period of almost 9 and other.
years.16 By having one surgeon record perioperative delays,
as well as their perceived causes, for all elective surgeries Statistical analyses
performed during a 9-year period, we present a method for
regularly documenting perioperative delays in detail. We We determined the number and cause of the delays in all
focus on perioperative system delays, which are delays in cases. We performed subgroup analyses for the following
the operating room due to system inefficiencies; that is, fail- categories: first case of the day versus second and third
ures of either the process or equipment. System delays need (i.e., subsequent) cases, cranial versus spinal cases, awake
to be differentiated from delays that are due to human fac- brain tumour surgery versus under general anesthesia, and
tors, such as experience or skill of the surgeon. We analyzed inpatient versus outpatient surgery. Except for in the first
the prevalence, causes and impact of perioperative system
delays that occurred in one neurosurgeon’s practice. We Table 1. Overview of all surgeries
highlight some principles underlying the causes of periop- performed between March 2000
erative delays across surgical subspecialties and emphasize and February 2009
the importance of recording perioperative delays. No. (%) of
Category neurosurgeries
METHODS Total 1531
Procedure
Study design Cranial surgery 1232 (80.5)
Spinal surgery 299 (19.5)
Order
All patients undergoing elective surgery with the senior
First case of the day 745 (48.7)
author (M.B.) between May 2000 and February 2009 were
Second or third case 786 (51.3)
entered prospectively into an observational study that the of day
identified and recorded all errors.16 We excluded emer- Anesthesia
gency and after-hours cases. The senior author entered all Awake 528 (34.5)
errors into the database immediately after each case. All General anesthesia 1003 (65.5)

data gathered during this study were kept confidential. The Admission status
Inpatient 1092 (71.3)
study was approved by the Research Ethics Board of the
Outpatient 439 (28.7)
University Health Network.
o
190 J can chir, Vol. 53, N 3, juin 2010
 RESEARCH

subgroup analysis, we included only first cases of the day majority of errors (33.6%). In total, 51.4% of all cases had
to limit the number of variables. Furthermore, we in- at least 1 delay and 88.5% had at least 1 error.
cluded only first-case brain tumours in the analysis based First cases had significantly more delays than second
on the type of anesthesia and patient’s admission status and third cases (Table 3), and cranial cases had more delays
(i.e., scheduled for admission v. outpatient). We also per- than spinal cases. The type of anesthesia used and the
formed a cost analysis based on hourly rates of pay at the patient’s admission status did not have a significant effect
Toronto Western Hospital (TWH). on the frequency of delays.
We performed Student t tests for normally distributed We also determined whether an initial delay was associ-
variables and Wilcoxon rank-sum tests for variables that ated with subsequent delays. After counting the mean
were not normally distributed. We set the significance number of delays, we subtracted 1 from this value to
threshold at p < 0.05. We analyzed the data using account for the initial delay. We found that there were sig-
Microsoft Excel and SAS version 9.1.3 (SAS Institute Inc.). nificantly more delays in second and third surgeries if there
had been a delay in the first surgery of the day (Table 3).
RESULTS Table 4 compares the causes of delay in cranial and
spinal procedures. Equipment failure was the most com-
A total of 1531 elective neurosurgical cases were included. mon source of delay in both groups, but cranial cases had
An overview of the cases is provided in Table 1, and the more initial delays (i.e., patient arriving late in the operat-
types of errors identified are listed in Table 2. System ing room), whereas spinal cases had more delays because of
delays, which included equipment failures, made up the waiting for an intraoperative localizing radiograph.

Table 2. Types of errors that

Cost analysis
occurred during the study period
About 10 000 surgical cases are performed at TWH each
No. (%) of
Type of error errors year. Of these, about 3000 are the first case of the day.
Delay 1180 (33.6)
We estimated that, if each delay lasts 10 minutes, the cost
Technical 923 (26.3) of nursing and operating room attendants (i.e., porters)
Contamination 859 (24.4) for each 10 minute delay is $18 based on the current
Nursing 186 (5.3) hourly pay rate for both. During the study period, there
Anesthesia 160 (4.6) were about 135 delays per year (1180 delays over 8.75 years),
Management/judgment 91 (2.6) which translates to $2430 per year. If we extrapolate this
Communication 47 (1.3)
cost to the entire department of surgery at TWH (which
Other 66 (1.9)
includes neurosurgeons, orthopedic surgeons, general
Total 3512 (100.0)
surgeons, plastic surgeons and urologists), and if we
assume that other operating rooms have a similar preva-
Table 3. Mean number of delays during the study period lence of delays, the total additional cost because of delays
per year is about $138 857. This is likely a gross underes-
Category No. of delays, mean (SD) p value
timate of the real financial costs. We did not account for
All cases 0.77 (0.92)
Order < 0.001
First case of the day 0.92 (0.97)
Table 4. Causes of delays in cranial
Second and third cases 0.63 (0.85) and spinal procedures
of the day
Procedure* < 0.001 % of
Cranial 1.00 (1.01) Procedure; cause of delay delays
Spinal 0.70 (0.82) Cranial
Anesthesia† 0.58 Equipment failure 57.9
Awake 1.08 (1.05) Getting into the OR 35.8
General anesthesia 1.03 (1.00) Quick section 2.4
Admission status† 0.18 Other 3.9
Inpatient 1.11 (1.03) Total 100.0
Outpatient 0.98 (1.00) Spinal
Presence of initial delay 0.033 Equipment failure 55.2
Yes 0.69‡ (0.80) Intraoperative radiograph 22.1
No 0.57 (0.82) Getting into the OR 17.2
SD = standard deviation. Other 5.5
*First cases only. Total 100.0
†First-case brain tumours only.
‡We subtracted 1 from this value to eliminate the value of the initial delay. OR = operating room.

Can J Surg, Vol. 53, No. 3, June 2010 191

RECHERCHE

the occasional cases cancelled at the end of the day delays in our study. Differences between authors in the
because of delays throughout the day, the cost of paying identification of the most common causes for delays reflect
nurses overtime for cases that extend after regular hours the variability between patient populations and systems at
because of previous delays during the day and the psycho- various hospitals, as well as the changing causes of perioper-
logical costs to patients and their loved ones, surgeons ative delays over time with the advancement of technology.
and anesthetists. Our subgroup analyses revealed that the first case of the
day was associated with significantly more delays than the
DISCUSSION subsequent cases; the potential reasons for this are outlined
in Box 1. Because an operating room may have several first
Delays in the operating room negatively affect both cases starting at the same time among all surgical subspe-
patients and health care workers. Although not all delays cialties, the same factors that delay first cases in neuro-
directly affect patient health, they often increase anxiety surgery probably also affect other subspecialties at our
for patients and their families and are a source of frustra- institution. First cases probably have a higher incidence of
tion for surgeons and other staff.15 However, Dexter and delays than subsequent cases because several operating
colleagues17 argue that saving time in the operating room rooms are preparing to start simultaneously, causing an
does not necessarily increase efficiency because the increased demand on the services of the clerks at registra-
amount of time saved by working faster is not enough to tion, the imaging department, the nurses in the patient
allow an extra case to be completed. This is especially true holding area and the hospital porters. The number of these
in the neurosurgical operating room, where the average support staff remains constant throughout the day, whereas
operating time is usually longer than in general surgery or the first-case patients all arrive at about the same time, giv-
orthopedic operating rooms. However, even if no extra ing rise to a “bottleneck” situation early in the morning.
cases are accommodated, the time saved is still time that Because first cases do not all end at the same time, the sub-
can be used for other purposes by surgeons and anes- sequent cases start in a staggered fashion, with enough sup-
thetists, such as extraoperative patient care, teaching and port staff to attend to their needs.
research. For operating room staff, the additional free The rest of our subgroup analyses were performed
time can be used to help with other aspects of overall using first cases only. Isolation of first cases allows for
operating room function. Finally, for patients, performing clearer identification of delays that are due to system defi-
operations on time would improve satisfaction with their ciencies and limits the variables that may affect punctuality.
experience at the hospital.15 Compared with subsequent cases, first cases are more
In this study, we focused exclusively on perioperative homogeneous and have fewer confounding variables, which
system delays. These are defined as delays due to system tend to appear later in the day. For example, the second
deficiencies in the operating room, which were classified in case may be affected by the length and conduct of the first
the error database as failures of process (“delay”) and case, whereas no such conditions exist for the first case.
equipment (“equipment failure”). We arbitrarily catego- Cranial surgeries are more frequently delayed than are
rized any missing or malfunctioning equipment as a form spinal surgeries. This situation may not be universally
of delay because fixing the instrument or procuring a new
item invariably wastes time. In fact, Khan and colleagues18
calculated that a fallen instrument causes an average delay Box 1. Possible reasons for a late start of first cases of the
day in the operating room
of 7.6 minutes. Other types of errors, such as technical or
• Patient arrives late from home
communication errors, may also lead to delays but these
• Suboptimal prioritization of multiple surgical navigation MRI scans
are more dependent on human and interpersonal factors • Delayed transfer of patients from imaging, admissions or wards
rather than on system failures. • Slow registration of patients in the admissions departments
We calculated that more than half (51.4%) of all cases • Anesthetist arrives late to check the patient in the holding area
have at least 1 delay and that each case has an average of • Surgeon arrives late to check the patient in the holding area
0.77 delays. This value is slightly higher than the number • Late patients are not tracked aggressively enough by nurses in the
holding area
reported by Overdyk and colleagues,8 which was 0.63 de- • Delayed surgical set-up of the OR by nurses
lays per case before intervention and 0.49 delays per case • Random events (e.g., patients having to go to the washroom just
after intervention. In our study, the most common cause of before being taken into the OR)
delay was equipment failure (55.2%–57.9%). Harders and • Delays because of waiting for a radiograph technician or insufficient
technicians available if multiple spinal ORs are to be run
colleagues 15 found that the second most commonly simultaneously
recorded reason for delay in the operating room, after • Equipment failure (e.g., e-film monitors in the OR)
patient clinical condition, was the availability of instru- • Inadequate number of nursed beds available
ments. However, the most common reason cited by • Inadequate number of nursing and anesthesia staff and OR facilities
for an unplanned emergency surgery
Overdyk and colleagues 8 for perioperative delays was
MRI = magnetic resonance imaging; OR = operating room.
unavailability of the surgeon; this was not the cause of any
o
192 J can chir, Vol. 53, N 3, juin 2010
 RESEARCH

applicable because in our institution all cranial surgery cause of perioperative delay is probably a universal phe-
patients undergo imaging, usually magnetic resonance nomenon, given the heavy dependence of many surgical
imaging (MRI), around 6 am on the morning of the specialties on equipment in recent years. Analysis of cranial
surgery; this MRI is used for neuronavigation purposes. versus spinal cases shows how additional procedures, such
Spinal surgery patients do not require similar preoperative as imaging, that are dependent on technology and coordi-
imaging. The amount of time needed to perform the imag- nation of operating room staff significantly increase the
ing adds to the delay, especially because there may be up to incidence of delays. Our analysis of awake versus general
4 surgical cranial cases scheduled to start at 8 am (as well as anesthesia procedures suggests that neither of these 2 types
2 or 3 stereotactic radiosurgery cases that also require MRI of anesthesia significantly affects efficiency. Because neuro-
early in the morning). The hypothesis that preoperative surgery shares limited operating room space and time with
imaging contributes to delays was supported by our finding other subspecialties, it is likely that the same system fail-
that a higher proportion of cranial cases (35.8%) are ures increase the incidence of delays in first cases across
delayed getting into the operating compared with spinal subspecialties. Similarly, our analysis of patient admission
cases (17.2%). In contrast, spinal cases require intraopera- status is relevant to all subspecialties at our institution
tive radiographs to confirm the correct level; intraoperative because all surgical patients undergo similar admission
imaging was the second most common cause of delay in processes. Finally, given that the reasons we suggest for
spinal cases, after equipment failure. Our results demon- delays getting into the operating room are common in the
strate that surgeries with extra steps such as imaging tend surgical operating room, the association between an initial
to have higher incidences of delays. delay and additional subsequent delays may be applicable
Because brain tumours make up the majority of the to other surgical subspecialties.
senior author’s practice, our analysis of cases by type of
anesthesia and patient’s admission status was limited to this Suggested solutions
patient group, which is a fairly uniform population with
limited confounding variables. Our analysis showed that Box 1 lists the possible reasons for delays getting into the
there was no difference in the mean number of delays operating room. Most of these reasons pertain to all surgi-
between patients who had awake surgery and those who cal specialties; however, suboptimal prioritization of MRIs
had general anesthesia. Likewise, there was no difference is more specific to imaging-dependent surgical procedures
in the mean number of delays between patients scheduled such as cranial neurosurgery.
for admission and those whose surgery was on an outpa- There are potentially easy remedies for many of these
tient basis. The category of admission status was meant to delays. To address late patient arrivals, a reminder phone
examine the patient registration process, which is the same call could be made to each patient the day before his or her
registration process used in other surgical subspecialties in surgery to decrease the chance of the patient arriving late
our institution; inpatients come in through the same day on the day of surgery. Prioritizing the order of MRIs the
admission unit, whereas outpatients are registered at the day before by a surgeon or operating room nurse might
day surgery unit. Our results indicate that the performance help to optimize MRI scheduling; for example, the MRI
of both units was comparable in terms of delays, which for an outpatient whose surgery is scheduled to start at
might be expected because the same physical unit and 8 am should be performed before that of a patient who is
nursing staff are used for both groups of patients. scheduled to have surgery at noon. Alternately, the regis-
Finally, we used our database to evaluate the impact of tration of the surgical navigation device could use a
perioperative delays. We asked whether an initial delay is recently obtained MRI, thus eliminating the need for
associated with more subsequent delays. Our analysis imaging on the day of surgery. To address delays in trans-
shows that this is indeed the case, because initially delayed fer by porters, each operating room should have an ade-
cases have a higher average number of subsequent delays quate number of dedicated porters, and they should be
compared with cases that are not delayed, even after sub- strategically deployed.
tracting 1 delay for the initial delay from the calculation. Having staggered start times for different operating
Initial delays may be associated with further delays because rooms might decrease delays because the finite pool of
there is already deviation from the schedule from the start, human and other resources would not be overtaxed before
setting off a “domino” effect. Moreover, the anxiety and the universal 8 am start for all operating rooms. To address
frustration felt by the operating room team over the delay delays because of waiting for radiograph technicians, extra
may affect their subsequent performance and contribute to radiation technologists should be assigned by a manager
more delays. Repercussions from delays in the operating overseeing the operating list on days when there are multi-
room are shared experiences across surgical subspecialties. ple spinal cases starting at 8 am. Implementing a reliable
The findings of our study illustrate the principles process to regularly screen equipment for malfunctions by
underlying the causes of perioperative delays in surgery in nurses or engineers would decrease the incidence of unan-
general. Our finding that equipment failure is a major ticipated equipment failures during surgery.

Can J Surg, Vol. 53, No. 3, June 2010 193

RECHERCHE

Other causes of delays might entail more long-term, go through before he or she enters the operating room. To
complex solutions. Resolving causes such as patients not pinpoint the exact cause of the delay, a neutral observer
being registered quickly enough, late patients not being who is not part of the surgical team would have to shadow
located quickly enough, delays in setting up the operating a patient from the time of arrival in the hospital until the
room and late arrivals of anesthetists or surgeons would end of the operation and meticulously record all causes of
require a change in the culture of the operating room, and system delays as they occur.
all members of the operating room team would need to be Our financial analysis was crude and does not accurately
more conscientious of scheduling and efficiency. The first reflect the actual lost costs because of delays. Furthermore,
step in this process would be to develop a transparent sys- we did not quantitatively or qualitatively assess the human
tem to monitor efficiency.8 Some random events, such as costs of delays on patients and surgeons.
patients having to go to the washroom just before being There is as yet no implementation plan to institute mea-
taken into the operating room, could possibly be mitigated sures to prevent delays and errors on a system-wide basis in
by enhancing communication between patients and operat- our institution. Certainly, the awareness of these flaws has
ing room staff. Major investment of additional resources by resulted in a conscious effort on the part of the surgical team
the hospital and funding governmental bodies will be and the rest of the staff to avoid them, but they still happen
required to solve the issue of inadequate beds and nursing with alarming frequency. We hope that the data from this
and anesthesia staff. study can be used to show that delays do happen frequently
and to elevate awareness about them so that appropriate
Limitations steps can be taken to prevent them. One could start by
addressing the causes of delays described in Box 1 and
This study has several limitations. First, all delays were attempting to put other systems in place to mitigate these
recorded by the senior author based on his personal crite- causes of delay. This could improve quality assurance in the
ria. Although having only one observer eliminates inter- operating room, patient satisfaction and flow, and decrease
observer variability, it can give rise to bias in how the frustration and anxiety on the part of the surgical team.
delays are identified and classified. However, this kind of
study is often generated by one committed individual, CONCLUSION
especially if others are not keen to participate. This was
the case in our study; thus, having only one recorder was This study demonstrates that perioperative system delays
the only option. Furthermore, recording delays is not as are a common type of error in the neurosurgical operating
subjective as recording other errors, because the former room and that lessons from analyses of perioperative delays
involves a quantitative measurable variable (time). in neurosurgery are applicable to other surgical disciplines.
Another important limitation is the way in which errors Furthermore, an initial delay is associated with additional
were classified. Some errors may have multiple causes and subsequent delays, propagating a vicious cycle. The most
be eligible for inclusion in more than 1 category. However, common types of delays were equipment failures and delays
errors were classified as only 1 type based on the discretion in getting the patient into the operating room; measures
of the senior author. For example, some delay or equipment devised to combat inefficiency in the operating room will
failure errors may have been caused by a combination of have to primarily target these areas. Such system improve-
human factors and system deficiencies, but these errors ments will require a dedicated collaborative effort at multi-
were only placed in 1 category. This ambiguity could be ple levels, including imaging departments, porter systems,
resolved by creating a more detailed classification system patient registration processes and others. Thorough docu-
that eliminates as many overlapping factors as possible. mentation of perioperative delays and their causes in differ-
The third limitation is the limited scope of the study pop- ent surgical subspecialties may be a useful way to start
ulation. This database was limited to the patients of a single designing solutions to improve operating room efficiency.
neurosurgeon whose practice consists mainly of patients
with brain tumours operated on in a large teaching hospital. Competing interests: None declared.
This enhances the reliability but weakens the generalizability Contributors: Ms. Wong and Dr. Bernstein designed the study and
of the results. Furthermore, we included only elective cases. acquired and analyzed the data, which Drs. Khu and Kaderali also ana-
lyzed. Ms. Wong wrote the first draft of the article. All authors reviewed
The fourth limitation deals with the classification of the the article and approved its publication.
system delays. There is no established classification in the
literature; thus, we developed our own system, which has References
not been validated. Furthermore, this classification is not
very specific, and it does not identify the exact reason for 1. Etchells E, O’Neill C, Bernstein M. Patient safety in surgery: error
detection prevention. World J Surg 2003;27:936-41; discussion 941-2.
the delay, especially for cases that were delayed getting into
the operating room. Such a delay could have stemmed 2. Eldar S, Nash E, Sabo E, et al. Delay of surgery in acute appendicitis.
from any step in the multiple processes that a patient has to Am J Surg 1997;173:194-8.

o
194 J can chir, Vol. 53, N 3, juin 2010
 RESEARCH

3. Kassell NF, Kongable GL, Torner JC, et al. Delay in referral of 11. Strum DP, Vargas LG, May JH. Surgical subspecialty block utilization
patients with ruptured aneurysms to neurosurgical attention. Stroke and capacity planning: a minimal cost analysis model. Anesthesiology
1985;16:587-90. 1999;90:1176-85.

4. Kreder HJ, Armstrong P. A review of open tibia fractures in children. 12. Sokal SM, Craft DL, Chang Y, et al. Maximizing operating room
J Pediatr Orthop 1995;15:482-8. and recovery room capacity in an era of constrained resources. Arch
Surg 2006;141:389-95.
5. Moran CG, Wenn RT, Sikand M, et al. Early mortality after hip
fracture: Is delay before surgery important? J Bone Joint Surg Am 13. Dexter F, Epstein RH, Marcon E, et al. Estimating the incidence of
2005;87:483-9. prolonged turnover times and delays by time of day. Anesthesiology
2005;102:1242-8.
6. Robinson CM, Ludlam CA, Ray DC, et al. The coagulative and car-
14. Dexter F. Measuring the frequency of delays in admission into the
diorespiratory responses to reamed intramedullary nailing of isolated
PACU. J Perianesth Nurs 2007;22:293-4.
fractures. J Bone Joint Surg Br 2001;83:963-73.
15. Harders M, Malangoni M, Weight S, et al. Improving operating
7. Shiga T, Wajima Z, Ohe Y. Is operative delay associated with increased
room efficiency through process redesign. Surgery 2006;140:509-14.
mortality of hip fracture patients? Can J Anaesth 2008;55:146-54.
16. Stone S, Bernstein M. Prospective error recording in surgery: an analy-
8. Overdyk FJ, Harvey SC, Fishman RL, et al. Successful strategies for sis of 1108 elective neurosurgical cases. Neurosurgery 2007;60:1075-82.
improving operating room efficiency at academic institutions. Anesth
Analg 1998;86:896-906. 17. Dexter F, Coffin S, Tinker JH. Decrease in anesthesia controlled
time cannot permit one additional surgical operation to be reliably
9. McQuarrie DG. Limits to efficient operating room scheduling: scheduled during the workday. Anesth Analg 1995;81:1263-8.
lessons from computer-use models. Arch Surg 1981;116:1065-71.
18. Khan SA, Kumar A, Varshney MK, et al. Accidentally falling instru-
10. Dexter F, Macario A, Traub RD. Optimal sequencing of urgent sur- ments during orthopaedic surgery: Time to wake up! ANZ J Surg
gical cases. J Clin Monit Comput 1999;15:153-62. 2008;78:794-5.

Change of address Changement d’adresse

We require 6 to 8 weeks’ notice to ensure uninter- Il nous faut de 6 à 8 semaines d’avis afin de vous
rupted service. Please send your current assurer une livraison ininterrompue. Veuillez faire
mailing label, new address and the effective parvenir votre étiquette d’adresse actuelle, votre
date of change to: nouvelle adresse et la date de la prise d’effet du
changement, à l’attention du
CMA Member Service Centre
Centre des services aux membres de l’AMC
1870 Alta Vista Dr. 1870, prom. Alta Vista
Ottawa ON K1G 6R7 Ottawa ON K1G 6R7
tel 888 855-2555 or tél 888 855-2555 ou
613 731-8610 x2307 613 731-8610 x2307
fax 613 236-8864 fax 613 236-8864
cmamsc@cma.ca cmamsc@cma.ca

Can J Surg, Vol. 53, No. 3, June 2010 195